Adapting Early Communication Intervention to the Phenotypic Characteristics of Young Children with Language Impairment Part II

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1 Adapting Early Communication Intervention to the Phenotypic Characteristics of Young Children with Language Impairment Part II Ann P. Kaiser Vanderbilt University 1

2 Today s Talk Building a new generation of communication interventions Enhanced Milieu Teaching (EMT) Brief overview Research evidence EMT active ingredients Underlying model of communication development Core procedures Additions to core EMT Adapting EMT To Fit Learner Characteristics Profiles of four populations Adaptations to maximize social communication outcomes The Intervention Tool Box: Tools for Adapting EMT Summary and Conclusions 2

3 EMT Principles and Strategies 1. Promote adult-child communication now Notice and respond Follow the child s lead 2. Increase child engagement with objects and activities Child preferred activities Join the child in play and activity Teach play and participation 3. Expand the social basis of communicative interactions Arrange environment to increase engagement Teach joint attention strategies Balance turns (mirror and map) Increase person engagement 4. Teach child communication target forms to advance language Respond Model Expand Prompt 3

4 EMT Child Communication Goals 1. Increase duration of engagement Social (joint engagement ) Objects (play) 2. Increase rate of communication Emphasize spontaneous social initiations 3. Increase diversity of communication Same level forms More words and phrases More functions ( requests, comments, questions) Across more contexts 4. Increase complexity of communication Higher level forms Prelinguistic to linguistic, Mean length of utterances Complexity of utterance types 5. Increase independence Initiated social communication Generalization across contexts, people 4

5 Part II Adapting EMT 5

6 Review: EMT Active Ingredients Environmental arrangement to promote communication Play and engage Follow child s lead in play and activity Respond to child communication Model language in context Expand child communication** Use time delay to prompt requests or initiations Use Milieu Teaching Prompts to promote practice Teach across settings, activities and partners ** In 2 randomized trials, expansion has been the ingredient most highly correlated with child outcomes (Kaiser & Roberts, 2012; Roberts & Kaiser, under review) 6

7 What Children Bring to EMT Access to Input Intelligibility Fluency Person Object Activity Rate Form Functions Transparency to partners Mode Baseline Communication Engagement Strategies Learning Strategies Imitation Auditory memory Efficiency 7

8 EMT Modifications to Fit What Children Bring Provide alternative mode Signs SGD Teach partners mode Teach joint attention skills Support partner comprehension Mode Baseline Communication Engagement Strategies Learning Strategies Teach play Increase person engagement Teach coordinated joint attention Teach imitation Add discrete trials Increase dosage 8

9 EMT Active Ingredient Play and engage Follow child s lead in play and activity Respond to child communication Model language in context Expand child communication Use time delay to prompt requests or initiations Use Milieu teaching prompts to promote practice 9

10 EMT Active Ingredient Child Behavior Required to Access Active Ingredient Play and engage Engages with objects, partners Follow child s lead in play and activity Engages with objects, Participates in activity Respond to child communication Communicates verbally or nonverbally Model language in context Engages with objects in play or activity Imitates Learns from observation Engages with partners Expand child communication Communicates pre linguistically (gesture) or linguistically Mode is intelligible to partner Imitates or learns from observation Engages with partners Use time delay to prompt requests or initiations Use Milieu teaching prompts to promote practice Engages with partners Interested in objects, Has preferences Learns to make choices Has mode for production Responds to prompts ( in least to most sequence) Imitates, Engages with partners Learns from practice embedded in interactions 10

11 EMT Active Ingredient Child Behavior Required to Access Active Ingredient Modifications Play and engage Engages with objects, partners Teach play, Use person engaged activity to reinforce social engagement Follow child s lead in play and activity Engages with objects, Teach play Participates in activity Provide more motivating materials, choices Respond to child communication Communicates verbally or nonverbally Model language in context Engages with objects in play or activity Imitates Learns from observation Engages with partners Expand child communication Communicates pre linguistically (gesture) or linguistically Mode is intelligible to partner Imitates or learns from observation Engages with partners Use time delay to prompt requests or initiations Use Milieu teaching prompts to promote practice Engages with partners Interested in objects, Has preferences Learns to make choices Has mode for production Responds to prompts ( in least to most sequence) Imitates, Engages with partners Learns from practice embedded in interactions Modify mode Train partners to recognize communication, Target simple rate increases first Teach imitation skills Modify modeling to fit speech or mode characteristics Teach prelinguistic skills ( point, show, give) Increase intelligibility Make mode more transparent to partner Modify time delay (lessen production demand) until child regularly responds Choosehighly preferred objects Teach responding to prompts and least to most support sequence, Increase reinforcement for responding 11

12 Modifications of EMT JASPER + EMT [J-EMT] Teaches joint attention, symbolic play, regulation JASPER + EMT + AAC [J-EMT+ SGD ; Words + Signs] Teaches joint attention, symbolic play, regulation Includes speech generating device or signs for input and output Phonological Emphasis + EMT [PE-EMT] Models speech targets Recasts for speech + Discrete trial training [Rescue protocol] - Reduce prompt complexity, number of prompts [Simplify] + Increase Dosage [Dosage] + Support Partners to use mode and EMT [Partner] 12

13 Phenotypic Specific Modifications Population Modifications Mode Engagement Learning Strategy Support Baseline Communication Toddlers with Receptive/Express Delay No No Support partner as teacher Down syndrome + Sign or SGD Teach play +Dosage Support partner comprehension Cleft Lip +/or Palate Minimally Verbal ASD + Speech targets No +Recast + Speech practice + SGD Teach play, engagement +Dosage +Rescue Protocol: imitation, receptive language Increase rate of child talk Teach joint attention skills 13

14 EMT Active Ingredient Modification EMT Type Population Study Play and engage Teach play, Use person engaged activity to reinforce social engagement J-EMT ASD Minimally verbal ASD Kasari, et al., 2006 Kasari, Kaiser et al 2014 Kasari et al in progress Follow child s lead in play and activity Teach play Provide more motivating materials, choices J-EMT ASD Minimallyverbal ASD Kasari, et al., 2006 Kasari, Kaiser et al 2014 Respond to child communication Modify mode Train partners to recognize communication Target simple rate increases first Words & Signs J-EMT +SGD DS ASD Wright, Kaiser, Roberts & Reikowsky 2012; Kasari, Kaiser et al 2014; Model language in context Expand child communication Teach imitation skills Modify modeling to fit speech or mode characteristics Teach prelinguistic skills ( point, show, give) Increase intelligibility Make mode more transparent to partner Rescue protocol PE-EMT Words + Signs J-EMT +SGD J-EMT+ SGD Words + Signs Minimally verbal ASD Cleft toddlers DS Minimallyverbal ASD DS Kasari, et al in progress Scherer & Kaiser, 2011 Kaiser, Scherer,& Frey, in press Kasari et al 2006 Kasari, Kaiser et al, 2014; Kaiser Hampton, & Fuller, in progress Wright et al 2012 Use time delay to prompt requests or initiations Modify time delay (lessen production demand) until child regularly responds Choose highly preferred objects EMT Words + Signs/SGD Simplify to accept gesture Toddlers with receptive/expressive delay DS ASD toddlers Roberts & Kaiser 2012; 2015 Wright et al 2012; 2015 Use Milieu teaching prompts to promote practice Teach responding to prompts and least to most support sequence, Increase reinforcement for responding EMT Words + Signs Simplify Toddlers with receptive/expressive delay DS Minimally verbal ASD Cleft toddlers Wright et al 2012 Roberts & Kaiser, 2015 Kasari, Kaiser, 2014 Scherer & Kaiser, 2011; Kaiser, Scherer & Frey, in press 14

15 The Effects of a Parent-Implemented Language Intervention for Children With Language Impairment Megan Y. Roberts, PhD, CCC-SLP Ann P. Kaiser, PhD

16 Toddlers with Receptive/Expressive Delays Communication Challenges Problem behaviors Low rates of talking Low lexical diversity Adaptations Increase attention to positive behavior, plan routines, teach communicative alternatives Use responsiveness strategies to increase rate Model expanded vocabulary before and during early syntax targets 16

17 Toddlers with Receptive/Expressive Delays Study Component Design Intervention Measures Description Randomized Clinical Trial 45 Intervention, 43 Control EMT with Play Skills 28 sessions ( 4 workshops, 14 clinic, 10 home across routines) Parent + Therapist Pre, 6 wks, 12 wks, 18 wks (end of intervention) Standardized, observational, parent report Participants Average age: 31 months Average Bayley Cognitive Score: 85 Gender: 83% male PLS-4: Roberts, M.Y. & Kaiser, A. P. (2015). Early intervention for toddlers with language delays: A randomized controlled trial. Pediatrics, 134(4), doi: /peds

18 Parent + Therapist EMT 18

19 Intervention Group : Pre-Post Gains Standard Score Expressive language (PLS-4) Receptive language (PLS-4) Expressive vocabulary (EOWPVT-3) Pre Post 19

20 Outcomes Intervention vs. Control d =0.3 d =0.3 d =0.3 d = Standard Score Expressive language (PLS-4) Receptive language (PLS-4) Expressive vocabulary (EOWPVT-3) Receptive Vocabulary (PPVT-4) Intervention Control 20

21 Outcomes Intervention vs Control: Number of Different Words Number of Different Words d = d = d = MCDI T: 264 C: 215 D =0.4 0 Start Month 1 Month 2 Month 3 Treatment Control 21

22 COMMUNICATION INTERVENTIONS FOR MINIMALLY VERBAL CHILDREN WITH AUTISM Kasari, Kaiser, Goods, Nietfeld, Mathy, Landa, Murphy, & Almirall (2014) Clinical Trials Number: NCT This study was funded by Autism Speaks #5666, Characterizing Cognition in Nonverbal Individuals with Autism (CCNIA).

23 Children with Autism Study Component Design Intervention Measures Participants Description Randomized Clinical Trial; Multiple Baseline AAC, Verbal only EMT + Joint Attention and Symbolic Play 48 sessions in the clinic (24 therapist only, 24 parent + therapist) Pre, Post, 6 months Standardized, observational, parent report Average age: 6 years, 6 months Average Leiter: 61 Gender: 74% male PPVT: 32 23

24 Children with Autism Communication Challenges Difficulty with joint engagement Adaptations Model and teach joint engagement behavior Few play skills and brief duration of play Requesting rather than commenting Interfering behavior Very low rate spoken language Model and teach play skills Model commenting, limit requesting Determine which behaviors are communicative; respond differentially Add SGD 24

25 Children with Autism Study Component Design Intervention Measures Participants Description Randomized Clinical Trial EMT + Joint Attention and Symbolic Play (J-EMT) 48 sessions in the clinic (24 therapist only, 24 parent + therapist) with/ without SGD Pre, Post, 6 months Standardized, observational, parent report 61 children with ASD Average age: 6 years, 6 months Average Leiter: Gender: 74% male PPVT: 32 Mn words at pre: Kasari, Kaiser, et al, 2014

26 Intervention Variations J-EMT Spoken Language Only J-EMT + SGD Speech Generating Device - Dynavox or ipad Model using spoken language and SGD At least 50% of utterances, 70% of expansions Child could speak or use SGD to respond and communicate 26

70% of adult expansions Child could respond to prompts with

27 Use of SGD SGD available to the child Programmed pages for toys sets Used communicatively with the child 50% of adult utterance 70% of adult expansions Child could respond to prompts with either SGD or spoken language Embedded in JASPER- EMT interactions 27

28 Results 70% of whole group met criterion for response to treatment at week 12 Greater percentage of participants in the JASP + EMT+ SGD group (77%) were early treatment responders than in the JASP +SGD group (62%) Participants in the JASP + EMT +SGD group had : more Social Communicative Utterances (SCU), greater Number of Different Word Roots (NDW), more comments (COM) than participants in JASP+ EMT group Both groups shows gains over time in SCU and NDW; only the JASP+EMT+SGD group showed gains in COM 28

Results At 12 Weeks Baseline 12 weeks Treatment Responders TSCU TND W TCO M TSCU TND W TCOM JASP+ EMT 28.4 16.8 7.0 35.3 24.3 8.1 62.2% JASP + EMT + SGD 30.5 17.6 5.1 54.4 33.1 14.1 77.

29 Results At 12 Weeks Baseline 12 weeks Treatment Responders TSCU TND W TCO M TSCU TND W TCOM JASP+ EMT % JASP + EMT + SGD % (difference) % Effect Size P value NS NS NS NS Social communicative utterances (TSCU), Number of different word roots(tndw ) and number of comments (TCOM )were derived from a naturalistic language sample with a blinded clinician 29

30 Results for the primary outcome (Total Social Communicative Utterances).! JASP+EMT+SGD JASP+EMT Total Socially Communicative Utterances !!!!!! Week Open plotting characters denote observed means; closed denote model-estimated means. Error bars denote 95% confidence intervals for the model-estimated means.

31 Further adaptions for children with ASD Blending direct instruction with naturalistic teaching Population: Minimally Verbal 3-4 year olds with ASD Protocol: Direct instruction for core behavior by therapist Naturalistic teaching by therapist Naturalistic teaching by parent Clinic and home Teaching behavior and social support as a basis for naturalistic teaching Population: month old toddlers with ASD Protocol: Pre-teaching attention, sustained play, social engagement by therapist; pre-teaching parent behavior strategies Naturalistic teaching by therapist and parent Home 31

32 EFFECTS OF NATURALISTIC SIGN INTERVENTION ON EXPRESSIVE LANGUAGE OF TODDLERS WITH DOWN SYNDROME. Wright, C.A., Kaiser, A.P., Reikowsky, D.I., & Roberts, M.Y. (2013). Journal of Speech, Language, and Hearing Research, 56,

33 Children with Down Syndrome Communication Challenges Low rate of symbol infused joint attention Poor articulation skills Poor auditory memory/ strong visual skills Poor generalization across partners, settings Adaptations Model communication in joint engagement episodes Teach sign + word as mode Model words + sign Teach with multiple partners, settings, activities 33

34 Children with Down Syndrome Study Component Design Intervention Measures Participants Description Multiple Baseline Single Subject EMT Words + Signs 24 sessions at home Therapist + Parent Pre, Post, ever 3 months Standardized, observational, parent report Use of signs Gender: 1 male, 2 female Average age: 25 months (2.83) Average Mullen: 69 (8.04) Average PLS-Total Standard Score: (5.32) 34

35 Intervention Variation EMT Words + Signs Simplify and reduce prompting Parent training after responding to prompts was established with therapist 35

36 EMT Words + Signs for Young Children 3 Toddlers with DS mos Multiple Baseline Design Taught by SLP in Clinic Generalization to home activities with parents Phase 2, teaching parents Wright et al, under review with DS Parent Outcomes % Matched Turns % Targets % Expansions % Correct Time Delay % Correct Prompting % Target JA models Child Outcomes Number of Symbols Used Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Ryan 41% 90% 1% 74% 0% 48% 0% 83% 0% 94% 0% 82% Erin 36% 82% 7% 64% 3% 57% 0% 100% 0% 100% 0% 66% Jay 34% 95% 2% 75% 0% 60% 0% 100% 0% 100% 0% 80%

37 Further Adaptations for Children with DS Use ipad as an alternative to signs Strengthen therapist component 2 sessions per week with child only ( 45 minutes each) Based on previous outcomes for DS children ( Yoder et al, 2016) Train parents across social and activity routines at home as well as in play Pre-teach skills and strategies using direct instruction (Heidlage, in progress) Teach persistence, responding, prompt sequence Teach multiple responses to single stimuli (label, action) Teach label/action in matrix training format 37

38 EFFECTS OF EMT+PE ON THE LANGUAGE SKILLS OF YOUNG CHILDREN WITH CLEFT PALATE Kaiser, Scherer, Frey & Roberts ( in press) NIDCD 1R21DCOO

39 Children with Repaired Cleft Communication Challenges Low intelligibility Low rate of communication Often shy, nonresponsive to prompting Adaptations Recast unintelligible utterances, model phonological targets Use responsiveness strategies to increase rate of communicating Increase prompting after sessions 39

40 Children with Repaired Cleft Study Component Design Intervention Measures Description Pilot Randomized Clinical Trial 7 Intervention, 9 Control PE-EMT 48 sessions in the clinic Therapist only Pre, Mid, Post, 3 months, 6 months Standardized, observational, parent report Participants Average age: 25 months Average Bayley Cognitive Score: 101 Gender: 69% male PLS-4: 100 Scherer & Kaiser, 2010 NIDCD 1R21DC A1 40

41 Intervention Variation Phonological Emphasis PE-EMT Choose word targets with target sounds Recast for phonological correctness Simplify prompt sequence 41

42 Children with Repaired Cleft Number of Different Words T0 T1 T2 Intervention: 7 Control: 9 ES: d =.72 p =.02 Intervention Control Intervention: 4 Control: 6 42

43 Children with Repaired Cleft 100% Percentage of Consonants Correct 80% 60% 40% 20% 52% 34% 58% 57% 71% 78% 0% T0 T1 T2 Intervention Control 43

44 Tools for Practice Skills Needed for Effective Intervention Fluent in the use of EMT* Skills for training parents and partners* Skilled in the additional components JASPER AAC (sign or SGD) Speech recasting Discrete trial training 44 * Information available at

45 Tools for Practice Assessment & Progress Monitoring Structured Play Assessment * Language Sample* Transcribed Coded for gesture Words, MLU, rate of initiations, rate of communication, consonant production Speech assessments Arizona, PEEPS or language sample with consonants transcribed Baseline EMT session* Responsiveness to comments, TD, Prompts; Prompted and spontaneous verbal imitation Use of targets Imitation probe * Receptive language probe : receptive object and picture labeling Toy preference assessment (ongoing) * Information available at 45

46 Tools for Practice Progress Monitoring is Essential Every child presents unique challenges in implementing EMT How child is responding to the intervention is the test of whether the fit is right Adaptive treatments are the 4 th generation of language intervention Quick tools for monitoring: IGDI Trackers for session data for therapist and child * 46

Tools for Practice Fidelity and Dosage Matter Is the intervention being delivered at fidelity? Is the dosage of components within in the intervention sessions sufficient?

47 Tools for Practice Fidelity and Dosage Matter Is the intervention being delivered at fidelity? Is the dosage of components within in the intervention sessions sufficient? Models, expansions, prompts Is child responding to the active ingredients? Are sessions frequent enough, long enough? Do other partners need to be trained to increase dosage 47

EMT is a complex intervention The core of the intervention is always the social communicative connection between the child and the therapist The most important immediate

48 EMT is a complex intervention The core of the intervention is always the social communicative connection between the child and the therapist The most important immediate outcome is communication Fine tuning interventions to child needs and characteristics can improve outcomes, but only when the core the of the intervention is working. Last words 48

49 References Kaiser, A.P., & Roberts, M.Y. (2013). Parent-implemented enhanced milieu teaching with preschool children with intellectual disabilities. Journal of Speech, Language, and Hearing Research, 56, Kaiser, A.P., & Wright, C.A. (2013). Enhanced milieu teaching: Incorporating AAC into naturalistic teaching with young children and their partners. Perspectives on Augmentative and Alternative Communication, 22, Kaiser, A.P. & Roberts, M.Y. (2013). Parents as communication partners: An evidence based strategy for improving parent support for language and communication in everyday settings. Perspectives on Language Learning and Education, 20(3), Kaiser, A. P. & Hampton, L. H. (2016). Enhanced Milieu Teaching. In R. McCauley, M. Fey & R. Gilliam (Eds.) Treatment of Language Disorders in Children (2 nd Edition), (pp ). Baltimore: Brookes. Kasari, C., Kaiser, A.P., Goods, K., Nietfeld, J., Mathy, J., Landa, R., Murphy, S., & Almirall, D. (2014). Communication interventions for minimally verbal children with autism: Sequential multiple assignment randomized trial. Journal of the American Academy of Child & Adolescent Psychiatry. Advance online publication. doi: /j.jaac Wright, C.A., Kaiser, A.P., Reikowsky, D.I., & Roberts, M.Y. (2013). Effects of naturalistic sign intervention on expressive language of toddlers with Down Syndrome. Journal of Speech, Language, and Hearing Research, 56, Roberts, M., & Kaiser, A. (2012). Assessing the effects of a parent-implemented language intervention for children with language impairments using empirical benchmarks: A pilot study. Journal of Speech, Language, and Hearing Research, 55, Scherer, N., and Kaiser, A.P. (2010). Enhanced milieu teaching with phonological emphasis: Application for children with CLP in treatment of sound disorders in children. Chapter to appear in Williams, L., McLeod, S., & McCauley, R. (Eds.), Interventions for Speech Sound Disorders in Children. Baltimore: Brookes Publishing. 49

Acknowledgements KidTalk Research Team at Vanderbilt Jennifer Nietfeld, Stephanie Jordan, Suzanne Thrower, Courtney Wright, Lauren Hampton, Kelly Windsor, Julie Bryant, Lizzy Fuller, Jodi Heidlage,

50 Acknowledgements KidTalk Research Team at Vanderbilt Jennifer Nietfeld, Stephanie Jordan, Suzanne Thrower, Courtney Wright, Lauren Hampton, Kelly Windsor, Julie Bryant, Lizzy Fuller, Jodi Heidlage, Kim McCulla, Jennifer Cunningham, Emily Quinn, Families and children who participated in our studies Our collaborators Connie Kasari (UCLA) Danny Almirall (Univ of Michigan), Rebecca Landa (Kennedy Kreiger, Johns Hopkins Univ) Tristam Smith (Univ of Rochester) Nancy Scherer( ASU) Jennifer Frey ( GWU) Megan Roberts ( Northwestern Univ) Juliann Woods (FSU) Pamela Hadley I Univ Illinois) For more information Ann.Kaiser@Vanderbilt.edu 50

IMPROVING EARLY COMMUNICATION OUTCOMES FOR TODDLERS WITH DOWN SYNDROME

IMPROVING EARLY COMMUNICATION OUTCOMES FOR TODDLERS WITH DOWN SYNDROME. Ann P. Kaiser, PhD Vanderbilt University Jennifer Frey, Courtney Wright, Jodi Heidlage, Mollie Romano and Juliann Woods George Washington